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\� STATE I0 NUMBER 00000023557004 <br /> a <br /> AINER CONSTRUCTION LIBBER LINED(X1 08 UNKNOWN LIN1N09 OTHER3EPDXY LINING04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> 06 TAR OR ASPHALT ( 1 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING [ 1 01 DOUBLE-WALLED PIPE ( 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( l 07 NONE <br /> B ((CHHECKRA PROPRIATE•BOXIEST ( ( 1104 PRESSURE 05 <br /> PIPE <br /> 05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( [ <br /> 01 TRENT <br /> 6VSUAL IGROUND(WATER MONITORING WELLS (( )ID 07VPREESSSUREAPOR FTESTLLB 1(09 NONE05 EN( ) 10SOTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 I ) 02 ( ) 03 <br /> ( ) <br /> 01 ' ( ) 02 ( ) 03 <br /> t ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ! O1 ( 1 02 ( ) 03 <br /> f ] 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ] 02 f 1 03 <br /> f 1 Ol ( 1 02 f ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> .IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) Ol YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> COT PERSON PHONE W/AREA CODE <br /> 'DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />